Put on the sidelines of palliative care: a qualitative study of important barriers to GPs’ participation in palliative care and guideline implementation in Norway

Abstract

Background

Demographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient’s home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs’ participation in palliative care and implementation of the guideline.

Methods

We interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis.

Results

We identified four main themes as barriers to GPs’ participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP–patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice.

Conclusion

Significant structural and individual barriers to GPs’ participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP–patient relationship must be maintained throughout severe illness and at end-of-life.

KEY POINTS OF THIS ARTICLE

According to the Norwegian guideline for palliative care, the GP should have a central position in providing primary palliative care.

Recent research and public reports suggest that not all GPs have such a central role or adhere to the guidelines.

This study highlights individual and structural barriers that could be addressed to increase GPs’ participation in palliative care and aid the implementation of the guidelines for palliative care.

Keywords:

• palliative care
• primary care
• palliative medicine
• general practice
• advance care planning
• end-of-life care, transitions of care
• clinical practice guidelines
• Norway

Acknowledgements

The authors of this study would like to thank all the participating GPs for lending their time to participate. We also thank Marianne Rønneberg for assisting as an observer for three interviews and Linda Sivesind for translating the GPs’ quotes.

Disclosure statement

Ethics approval and consent to participate

The study was performed in accordance with the declaration of Helsinki and was approved by the Regional Committee for Medical and Health Research Ethics Central Norway (Regionale komiteer for medisinsk og helsefaglig forskningsetikk Midtnorge) (2017/903/REK midt). The study was approved by the Norwegian University of Science and Technology, NTNU, and carried out under relevant guidelines and regulations. All participants gave informed, written consent to participate in the study.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available. Norwegian legislation requires data to be stored on a password-protected file on a university server for reasons of confidentiality and privacy. Access to the data is restricted to a period after completion of the project. Data could be available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Additional information

Funding

This study was funded by the Norwegian Research Fund for General Practice, The Norwegian Committee on Research in General Practice, and The General Practice Research Unit, Norwegian University of Science and Technology. The funders had no role in data collection and analysis, selection of respondents, decision to publish, or preparation of the manuscript.